Provider Demographics
NPI:1578763355
Name:BERRY, MAX WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:WAYNE
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 PIPER STREET, STE A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-339-9455
Mailing Address - Fax:907-339-9445
Practice Address - Street 1:3650 PIPER STREET, STE A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-339-9455
Practice Address - Fax:907-339-9445
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD603439872085R0204X
SC309702085R0204X
AL316932085R0204X
TXQ99582085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01287745OtherRR MEDICARE
WA314118OtherL&I POST 7/21/13
WAP01287745OtherRR MEDICARE
WAG8921754, G8921755Medicare PIN